All records are legible and the name and designation of the service provider is identifiable.

The names and designations of service providers making entries into the residents’ clinical records and/or completing clinical assessment documentation are not clearly identifiable and/or legible.

The names and designations of services providers making entries into resident clinical records and/or completing clinical assessment documentation are legible.

PA Low

Reporting Complete

19/08/2015

Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).

The restraint monitoring form does not allow staff to record monitoring times following observation of the resident.

Provide evidence that the restraint monitoring form allows care staff to record when they observe the resident during restraint use.

PA Moderate

Reporting Complete

19/08/2015

Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.

The development of nursing care plans, the evaluation of those plans, and the completion of clinical assessments for new residents are not completed within required timeframes.

Each stage of service provision is provided within timeframes that safely meet the needs of residents.

PA Moderate

Reporting Complete

19/08/2015

The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.

Ongoing assessments of clinical concerns, such as resident pain, are not completed as clinically indicated. Clinical assessments such as weight, blood pressure, temperature and pulse, are completed irregularly.

The clinical status of residents is assessed / reassessed on a regular and as clinically indicated basis.

PA Moderate

Reporting Complete

19/08/2015

Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.

Quality improvement data is not being analysed and evaluated to identify trends.

Quality improvement data is analysed to identify trends and evaluated and this information reported back to staff.

PA Moderate

Reporting Complete

19/08/2015

A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.

Not all staff have attended challenging behaviour education and clinical staff files do not evidence restraint competencies.

Provide evidence that all staff have received challenging behaviour training and that all clinical staff have restraint competency assessments completed and that these assessments are ongoing.

PA Moderate

Reporting Complete

02/12/2015

Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.

Documentation was unable to evidence resident care plans were being regularly evaluated. Those evaluations that have been completed do not comprehensively record resident progress towards planned outcomes.

What’s on this page?

Audit reports for this rest home’s latest audits can be downloaded below.

Full audit reports are provided for audits processed and approved after 29 August 2013. Note that the format for the full audit reports was streamlined from 16 December 2014. Full audit reports between 29 August 2013 and 16 December 2014 are therefore in a different format.

Prior to 29 August 2013, only audit summaries are available.

Both the recent full audit reports and previous audit summaries include:

an overview of the rest home’s performance, and

coloured indicators showing how well the rest home performed against the different aspects of the Health and Disability Services Standards.

Note: From November 2013, as rest homes are audited, any issues from their latest audit (the corrective actions required by the auditor) will appear on the rest home’s page. As the rest home completes the required actions, the status on the web site will update.